Resource StructureDefinition/FHIR Server from package nictiz.fhir.nl.r4.zib2020#0.10.0-beta.1 (46 ms)
| Package | nictiz.fhir.nl.r4.zib2020 |
| Type | StructureDefinition |
| Id | Id |
| FHIR Version | R4 |
| Source | https://simplifier.net/resolve?scope=nictiz.fhir.nl.r4.zib2020@0.10.0-beta.1&canonical=http://nictiz.nl/fhir/StructureDefinition/zib-SOAPReport |
| Url | http://nictiz.nl/fhir/StructureDefinition/zib-SOAPReport |
| Status | draft |
| Name | ZibSOAPReport |
| Title | zib SOAPReport |
| Experimental | False |
| Realm | nl |
| Description | A SOAP report is a textual report of a (partial) consult with relation to a single problem according to the SOAP structure. SOAP (acronym for subjective, objective, assessment, plan) is a method used by health professionals to structurally record information that comes up during contact between the patient and a health professionals in the patient's record. The following standardized format is used for reporting:
* Subjective: the patient's complaint and request for help and the amnesic data
* Objective: the findings from the physical and supplementary examination.
* Assessment: the working hypothesis and the thinking process, for example a differential diagnosis of the healthcare professional.
* Plan: the diagnostic plan or treatment plan and what has been discussed or agreed with the patient.
The SOAP report is mainly used in general practice care.
Note: the zib doesn't state explicitly if zib SOAPReport pertains a consult or a partial consult, but it has become clear that the zib, and thus this profile, should be interpreted as a partial consult with relation to a single problem (see ). The text above has been adjusted according to this insight. |
| Purpose | This Composition resource represents the Dutch [zib ('Zorginformatiebouwsteen', i.e. Health and Care Information Model) SOAPReport v1.0 (2020)](https://zibs.nl/wiki/SOAPReport-v1.0(2020EN)). |
| Copyright | Copyright and related rights waived via CC0, https://creativecommons.org/publicdomain/zero/1.0/. This does not apply to information from third parties, for example a medical terminology system. The implementer alone is responsible for identifying and obtaining any necessary licenses or authorizations to utilize third party IP in connection with the specification or otherwise. |
| Type | Composition |
| Kind | resource |
Resources that use this resource
Resources that this resource uses
Source
{
"resourceType" : "StructureDefinition",
"id" : "zib-SOAPReport",
"url" : "http://nictiz.nl/fhir/StructureDefinition/zib-SOAPReport",
"name" : "ZibSOAPReport",
"title" : "zib SOAPReport",
"status" : "draft",
"publisher" : "Nictiz",
"contact" : [
{
"name" : "Nictiz",
"telecom" : [
{
"system" : "url",
"value" : "https://www.nictiz.nl",
"use" : "work"
}
]
}
],
"description" : "A SOAP report is a textual report of a (partial) consult with relation to a single problem according to the SOAP structure. SOAP (acronym for subjective, objective, assessment, plan) is a method used by health professionals to structurally record information that comes up during contact between the patient and a health professionals in the patient's record. The following standardized format is used for reporting:\r\n\r\n* Subjective: the patient's complaint and request for help and the amnesic data\r\n* Objective: the findings from the physical and supplementary examination.\r\n* Assessment: the working hypothesis and the thinking process, for example a differential diagnosis of the healthcare professional.\r\n* Plan: the diagnostic plan or treatment plan and what has been discussed or agreed with the patient.\r\n\r\nThe SOAP report is mainly used in general practice care.\r\n\r\nNote: the zib doesn't state explicitly if zib SOAPReport pertains a consult or a partial consult, but it has become clear that the zib, and thus this profile, should be interpreted as a partial consult with relation to a single problem (see <https://bits.nictiz.nl/browse/ZIB-1474>). The text above has been adjusted according to this insight.",
"purpose" : "This Composition resource represents the Dutch [zib ('Zorginformatiebouwsteen', i.e. Health and Care Information Model) SOAPReport v1.0 (2020)](https://zibs.nl/wiki/SOAPReport-v1.0(2020EN)).",
"copyright" : "Copyright and related rights waived via CC0, https://creativecommons.org/publicdomain/zero/1.0/. This does not apply to information from third parties, for example a medical terminology system. The implementer alone is responsible for identifying and obtaining any necessary licenses or authorizations to utilize third party IP in connection with the specification or otherwise.",
"fhirVersion" : "4.0.1",
"mapping" : [
{
"identity" : "zib-soapreport-v1.0-2020EN",
"uri" : "https://zibs.nl/wiki/SOAPReport-v1.0(2020EN)",
"name" : "zib SOAPReport-v1.0(2020EN)"
}
],
"kind" : "resource",
"abstract" : true,
"type" : "Composition",
"baseDefinition" : "http://hl7.org/fhir/StructureDefinition/Composition",
"derivation" : "constraint",
"differential" : {
"element" : [
{
"id" : "Composition",
"path" : "Composition",
"short" : "SOAPReport",
"comment" : "Zib SOAPReport is implemented using two profiles: this profile implements the SOAPReport concept of the zib, while <http://nictiz.nl/fhir/StructureDefinition/zib-SOAPReport.SOAPLine> represents the SOAPLine concept of the zib which is referenced by `.section.entry`. \r\nThe Composition resource SHOULD hold a summary in the `.section.text` elements of the information found in the referenced SOAPReport.SOAPLine profile.",
"alias" : [
"SOEPVerslag"
],
"mapping" : [
{
"identity" : "zib-soapreport-v1.0-2020EN",
"map" : "NL-CM:13.6.1",
"comment" : "SOAPReport"
}
]
},
{
"id" : "Composition.status",
"path" : "Composition.status",
"comment" : "Unless the status is explicitly recorded it is expected that only _final_ reports are exchanged."
},
{
"id" : "Composition.type",
"path" : "Composition.type",
"patternCodeableConcept" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "11591000146107"
}
]
}
},
{
"id" : "Composition.date",
"path" : "Composition.date",
"short" : "SOAPReportDateTime",
"definition" : "Date and time when the report was recorded",
"alias" : [
"SOEPVerslagDatumTijd"
],
"mapping" : [
{
"identity" : "zib-soapreport-v1.0-2020EN",
"map" : "NL-CM:13.6.2",
"comment" : "SOAPReportDateTime"
}
]
},
{
"id" : "Composition.author",
"path" : "Composition.author",
"short" : "Author",
"definition" : "The healthcare provider who prepared the report and who is responsible for its content.",
"alias" : [
"Auteur"
],
"max" : "1",
"type" : [
{
"code" : "Reference",
"profile" : [
"http://nictiz.nl/fhir/StructureDefinition/pattern-ZibHealthProfessionalReference"
],
"targetProfile" : [
"http://hl7.org/fhir/StructureDefinition/Practitioner",
"http://hl7.org/fhir/StructureDefinition/PractitionerRole",
"http://hl7.org/fhir/StructureDefinition/Device",
"http://hl7.org/fhir/StructureDefinition/Patient",
"http://hl7.org/fhir/StructureDefinition/RelatedPerson",
"http://hl7.org/fhir/StructureDefinition/Organization",
"http://nictiz.nl/fhir/StructureDefinition/zib-HealthProfessional-PractitionerRole"
]
}
],
"mapping" : [
{
"identity" : "zib-soapreport-v1.0-2020EN",
"map" : "NL-CM:13.6.3",
"comment" : "Author"
}
]
},
{
"id" : "Composition.title",
"path" : "Composition.title",
"definition" : "Official human-readable label for the composition. Suggested value is the ICPC display name on the A entry."
},
{
"id" : "Composition.section",
"path" : "Composition.section",
"slicing" : {
"discriminator" : [
{
"type" : "value",
"path" : "code"
}
],
"rules" : "open"
}
},
{
"id" : "Composition.section:soapLine",
"path" : "Composition.section",
"sliceName" : "soapLine",
"short" : "SOAPLine",
"alias" : [
"SOEPRegel"
],
"max" : "4",
"mapping" : [
{
"identity" : "zib-soapreport-v1.0-2020EN",
"map" : "NL-CM:13.6.4",
"comment" : "SOAPLine"
}
]
},
{
"id" : "Composition.section:soapLine.code",
"path" : "Composition.section.code",
"short" : "SOAPLineHeader",
"definition" : "The name of the SOAP line as a coded description. In a SOAP report this can be one of the following: subjective, objective, assessment or plan.",
"alias" : [
"SOEPRegelNaam"
],
"min" : 1,
"binding" : {
"strength" : "required",
"valueSet" : "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.6.2--20200901000000"
},
"mapping" : [
{
"identity" : "zib-soapreport-v1.0-2020EN",
"map" : "NL-CM:13.6.6",
"comment" : "SOAPLineHeader"
}
]
},
{
"id" : "Composition.section:soapLine.text",
"path" : "Composition.section.text",
"comment" : "This element SHOULD hold the information as found in the referenced [zib-SOAPReport.SOAPLine](http://nictiz.nl/StructureDefinition/zib-SOAPReport.SOAPLine) profile to provide a human-readable narrative of the Composition."
},
{
"id" : "Composition.section:soapLine.entry",
"path" : "Composition.section.entry",
"definition" : "A reference to data that supports this section. At a minimum, there should be an entry for the SOAPReport.SOAPLine profile.",
"min" : 1,
"type" : [
{
"code" : "Reference",
"targetProfile" : [
"http://hl7.org/fhir/StructureDefinition/Resource",
"http://nictiz.nl/fhir/StructureDefinition/zib-SOAPReport.SOAPLine"
]
}
]
}
]
},
"text" : {
}
}
XIG built as of ??metadata-date??. Found ??metadata-resources?? resources in ??metadata-packages?? packages.
FHIR